Triple play: Decision support, RBMs + rads must work together

While the future of imaging utilization management (UM) may include the expansion of radiology benefits managers (RBMs) and decision support (DS) systems, radiologists themselves also must take an active role, according to an article published in the October issue of the Journal of the American College of Radiology.

Because of the rapid growth in medical imaging in the previous decade, radiology has been a target of cost-containment initiatives, wrote Richard Duszak, Jr., MD, of University of Tennessee Health Science Center in Memphis, and Jonathan W. Berlin, MD, MBA, of the University of Chicago Pritzker School of Medicine in Evanston, Ill. As such, RBMs have gained traction in the market, though DS use remains limited.

“At first glance, RBMs and current DS tools may seem to be mutually exclusive processes. Evolving experience with pharmaceutical UM programs, however, instead suggests future complementary roles,” wrote the authors. They said real-time DS and payer preauthorization could soon resemble the model of payer-approved preprinted prescription forms with appropriateness criteria check boxes, but in electronic form.

The challenge, according to Duszak and Berlin, will be incorporating DS into insurer UM programs, as DS criteria today are generally institution-specific. To solve this, integrated systems in the future will need to pull payer-specific criteria from cloud-based hubs to align DS affirmation with coverage.

But DS systems and RBMs can only go so far. Non-interpretive services—locating prior images, designing protocols, discussing findings with patients and physicians—are often not documented in current payment systems. These services may actually result in reduced utilization on their own, explained the authors. For example, if a radiologist discovers a prior study duplicative of one that is newly requested, he may be able to forgo performing the new study, thus reducing utilization rates. Since these non-interpretive services aren’t tracked by many RBMs or DS systems, there could be an incentive to neglect this work and proceed with repeat studies.

Radiologists should be wary of turning all UM over to outside gatekeepers such as RBMs or DS, wrote Duszak and Berlin. “If insurers and health systems believe that turnkey third-party solutions are as good as, or better than, radiologists themselves for controlling unnecessary utilization, professional commoditization becomes almost certain.”

They added: “As national strategies to control health care costs evolve from historical unit cost reduction approaches to methodologies in which UM plays a larger role, radiologists will increasingly find themselves confronted with new challenges and opportunities. Their willingness and ability to embrace those changes will likely determine their fate as meaningful stakeholders in UM.”